In an Age of Images, Teaching Pathology by Hand

BOSTON — The patient’s decline was ruthless. He became forgetful in his early 50s. By the time he saw a neurologist a few years later, he could not recall how to write in cursive, and confused pictures of a cookie and a whistle, a bed and a sandbox.

A few years after that, he could no longer dress himself or speak fluently, and had developed muscle jerks that required medication to control. Diagnostically, he showed symptoms of several types of dementia, but no hallmarks that would narrow the cause to only one. He died in his early 60s.

On a Friday morning a week later, Dr. Jeffrey T. Joseph, a pathologist, was gazing at the patient’s brain, waiting for neurology residents to arrive and gaze with him. He pondered whether to begin the dissection with a traditional vertical slice down the height of the brain. “I might cut coronally, might cut horizontally,” he said, thoughtfully. “I haven’t decided yet.”

From a distance, brain autopsies seem an afterthought on life. Insurance does not cover them. They serve no lucrative purpose, so hospitals have a financial disincentive to do them. As a result, the field of neuropathology is shrinking, and its atrophy may diminish the entire field of neurology.

Neurology, after all, is a subscience of anatomy — the symptoms of brain disorders are directly related to the sites of lesions — yet many neurology residencies no longer require brain-cutting time. Without this experience, residents cannot lay eyes or hands on the organ that will be their lifeblood.

“Neuropathology as a freestanding subspecialty is going to disappear,” said Dr. Thomas Smith, professor of pathology and neurology at University of Massachusetts Medical School. “It’s going to be subsumed into general surgical pathology.” His department used to have two neuropathologists and a lab; now there is no lab and one doctor.

A few generations ago, neurologists in training spent months dissecting spinal cords and brains. “The main reason,” said Dr. Dan Press, assistant professor of neurology at Harvard Medical School (and a former student of Dr. Joseph’s, who still attends the seminars when he can), “was because there was no imaging then.”

Everything changed with the advent of magnetic resonance imaging. Now residents spend hours each week studying neuroradiology; M.R.I. and CT are the primary educational tools. As a result, they gain most of their anatomical knowledge from images. Specialty board examinations that used to be full of pathology pictures are now full of radiologic images.

“But pathology still allows a resolution that imaging never will,” Dr. Press said. “It forces you to see three-dimensionally. There’s no more concrete way to make it real. It’s the difference between looking at maps of a place and driving around it.”

Dr. Joseph has conducted a weekly neuropathology seminar at the Beth Israel Deaconess Medical Center at Harvard for more than 12 years. In the fall, he will leave Harvard to become a professor at the University of Calgary in Alberta. His seminar will move with him. “It’s part diagnosis, part entertainment,” Dr. Joseph said. “I like to make them look. The brain is like a geode — you don’t know what’s inside.”

A lively 52-year-old with sideburns and a Mephistophelean glint, Dr. Joseph wears a bow tie covered with dragons, or paramecia; he does not know which, because his wife — a neurologist who attended his seminar during her residency — buys them.

Photo

Dr. Jeffrey T. Joseph, a pathologist, leading a first-year resident, Dr. Scott Wenson, above left, through a brain autopsy at the Beth Israel Deaconess Medical Center at Harvard. Its part diagnosis, part entertainment, Dr. Joseph said of his neuropathology seminar.Credit
Photographs by Robert Spencer for The New York Times

The autopsy suite is in the basement of the hospital, behind an unmarked door with a discreet posting: “Funeral directors, please sign the log book.” Unlike the surgical pathology suite, where there are five high-grade cutting stations, the atmosphere here is left-behind; ventilation is old and loud, and sometimes it can be hard to find a pair of sharp scissors. Bach used to play in the background, until a senior pathologist remonstrated Dr. Joseph that the autopsy suite was not a place for music; it was sacred ground, a church. Dr. Joseph pointed out that Bach was often played in churches. The argument did not prevail.

Residents drift in — neurology tuning forks and reflex hammers poking from white pockets — and move toward the dissecting table, where blades and tweezers have been laid out beside several bulging towels in pans. Dr. Press is here, too; he was one of the physicians caring for the patient. Dr. Joseph unwraps one of the towels. It is the control case, a normal brain from a patient who died of unrelated illness.

“Nice and full,” Dr. Joseph says. “You see the gyri. We’ll compare him to No. 2.”

He turns to the other dish towel. Though his assistant usually removes the brain, in this case Dr. Joseph uses a hacksaw to open the skull, and then a kind of buzz saw to take out the brain and spinal cord. “It’s like carpentry, almost relaxing, in a sick way,” he says.

Carefully, he holds up the second brain and peels off the outer membrane lining. “Take a look. See what you see,” he says. He turns the brain over, holds it in his palm, and points. “What’s this?” Silence. “It’s a little bit of the optic nerve. You can see how a tumor would press right on it and affect vision. Imagine how close everything is.”

More silence. Everyone leans in. Dr. Press leans in farthest. He watches Dr. Joseph lay the two brains side by side and slice each axially with a 10-inch blade. “Perfect cut,” he says admiringly. “Oh, that’s beautiful.”

Dr. Joseph tells the residents, “Something’s very different,” and asks, “What’s wrong with this as a regular case of Alzheimer’s?” He points (there is a lot of pointing in a neuropathology seminar). The temporal lobes on each side are shrunken, characteristic for Alzheimer’s dementia. But the occipital lobe at the rear of the brain, where vision and visual perception occur, is also denser and simpler than in the control, with far fewer folds and indentations.

Dr. Press shakes his head at the sight. “This is why he got lost — right here. That’s why he couldn’t recognize me — right there,” he says.

Dr. Joseph continues: “This is almost certainly Alzheimer’s disease, if you’re a betting person. But very unusual because of the global atrophy — the primary visual cortex is gone. And he’s got a lot of extra space. I can put my finger through the whole ventricular system.” He does so, one blue finger disappearing into spaces where fingers do not belong.

“By the way,” he adds, “this is what a full-length spinal cord looks like.” He lifts it out of the pan. There are bright pinpoints along its membrane.

“That’s calcium,” Dr. Joseph explains. “Eggshell calcification. I like it because radiologists can’t see it. You only find it on the lower cord of older patients. When you think of it, really, the whole spinal cord is kind of puny.” One of the residents measures to himself with his hands, disbelievingly. The tunnel that transports man’s nervous infrastructure is about a foot and a half long and the width of a pinkie.

After the residents leave, Dr. Joseph will cut more slices from the temporal and occipital lobes, isolate sections, embed them in paraffin, stain them for slides and examine them. It will take a few weeks to confirm what everyone could see.

But the teaching seminar has gone over time. Beepers beep; demands from the still-living. “You guys can go if you need to,” he says to the residents. Everyone has someplace else to be.

But for another minute, no one leaves.

A version of this article appears in print on , on page F6 of the New York edition with the headline: In an Age of Images, Teaching Pathology by Hand. Order Reprints|Today's Paper|Subscribe